Catalin Cirstoiu

Fixation System Design in Ipsilateral Proximal Femur and Diaphyseal Fractures in Elderly Patients

Ipsilateral proximal femur combined with diaphyseal fracture is a rare and problematic combination of injuries with serious potential complications first reported in the literature by Delaney and Street in 1953. This paper offers a retrospective view of 21 cases involving ipsilateral, proximal and diaphyseal fractures in elderly patients who were treated in our department, in order to emphasize the challenges of managing these pathological entities in elderly patients and the need for improvement of implant design. A number of 21 patients treated in our department, over a five year period for ipsilateral, combined proximal (intertrochanteric or femoral neck fractures) and femoral shaft fractures was selected. The cases were the result of various types of trauma as follows: 8 patients injured in motor vehicle accidents, 11 falls from standing position and 2 falls from more than own height. No open fractures or pathological fractures were recorded for this study. The patients were grouped according to treatment approach as group A (n=13), managed using intramedullary fixation devices and group B (n=8), treated with plating. All 21 patients were followed-up for 1 to 2 years after surgery. The data was analysed using Students t-test and a comparison between the two groups was devised. None of the available fixation methods has shown clear superiority for addressing this fracture association. The multitude of variables affecting the management of this injury pattern is complemented by the poor local biomechanical environment provided by the low bone mineral density characteristic for the elderly patients. This raises the challenge of improving the design of the implants to better suit the biomechanical requirements, which sometimes are dictated by the age of the patients.

Mechanical Failure of Angle Locking Plates in Distal Comminuted Tibial Fractures

Distal comminuted tibial fracture with or without intra-articular involvement is a very common injury of the lower limb, especially in younger patients due to high energy trauma. The anatomical and biomechanical properties of this segment of tibia, makes this pathology a major surgical challenge with a preserved clinical outcome. The aim of this study is to present different outcome of tibial fracture, treated with open reduction and internal fixation (ORIF) with titanium angle locking plates (ALP) and to underline the physiological and non-physiological bone healing effects on implants. In this study we included 48 patients with tibial pilon fracture who underwent to ORIF, applying ALP in the Orthopedics and Trauma department of the University Emergency Hospital in Bucharest. Due to preserved biomechanical properties of ALP and this anatomical region, weight bearing is not allowed till 6 to 8 weeks. Comminuted fracture of this part of tibia often have de-vascularized bony fragments which leads to delayed union or non-union. These complications often lead to implant failure, improper bone healing or non-union. Internal fixation with angle stable screws, offers a good stability of reduction in the early postoperative period. Titanium angle locking plates offers good anatomical reduction and stable fixation in the early period of healing process. Due to its rigid, fixed position of the screws in the plates, bone remodelling during healing process and early weight bearing, increases the mechanical failure of implant.Keywords: tibial pilon fractures, angle locking plates, implant failure.

Short Term Behaviour of Fixed-Loop Cortical Suspension System Used for Surgical Treatment of Hallux valgus

Hallux valgus represents an acquired foot deformity characterized by lateral deviation of the hallux and medial deviation of the first metatarsal. Pain during gait is the main complain and is caused by reduction of plantar pressure under the first ray leading to insufficiency of the first ray and overload of the lesser rays. Treatment can be nonoperative or surgical with more than one hundred surgical techniques described so far. The scope of this study was to assess the short term reliability and stability of fixed loop suspension systems used for surgical treatment of this pathology using radiological evaluation of hallux valgus angle and the intermetatarsal angle. Our results show good stability of the reduction and good reliability of the suspension system, with a six months follow-up. Only one specific complication (failure of the wiring material) is highlighted by our conclusions and the need for biomechanical testing in controlled laboratory studies.

Bioabsorbable Anchors for Medial Patellofemoral Ligament Reconstruction

Acute dislocation of the patella is a very common injury of the knee. In more than 90% of the cases the medial patellofemoral ligament (MPFL) is injured. Reconstruction of the MPFL has become a popular soft tissue procedure, which reduces hospitalization and the rehabilitation period. Bioabsorbable materials, in form of screws and anchors are ideal for soft fixation to bones in orthopedics. We would like to present our experience and short-term results after MPFL reconstruction with semitendinous autograft and bioabsorbable fixation devices. 10 patients were involved in this study with PF joint instability, who underwent to MPFL reconstruction. In order to evaluate the functional outcome of the procedure we applied the Tegner Lysholm scoring system before and after 3 Months of surgery. MPFL reconstruction significantly improved the functionality of the PF joint. Gender distribution of the studied group was: 7 female with an average age of 25 5,03 SD and 3 male patients with an average age of 29 1 SD. The key for the success in MPFL reconstruction is the positioning of the femoral tunnel, followed by an isometric tensioning of the graft. Bioabsorbable materials reduce inflammatory, and foreign body response facilitating biointegration of the autograft.

Influence of Antibiotics Addition in Bone Cements for Hip Arthroplasty on their Mechanical Properties: Clinical Perspective and In Vitro Tests

Bone cement has been used for over half a century, to successfully anchor artificial joints. From its emergence there have appeared a number of types of bone cement, with the 2 major classes being bone cement with or without active substances. The one with the added antibiotics is used primarily in the treatment and revision surgery of infected total hip arthroplasty (THA), as well as a prophylactic method in primary THA in patients with high risks for this complication. The purpose of this study is to determine the mechanical properties of bone cement with added antibiotics. Over a period of 2 years, a number of 41 cases were chosen for this study: 25 with revision surgery for THA, where bone cement with antibiotics was used, and 16 with primary THA, where regular bone cement was used. A number of studies have been performed on the mechanical properties of the 2 types of cement, which determined that the cement with antibiotics presents a slightly lower compressive strength, tensile strength, elastic modulus and fatigue strength compared with regular cement. These variations, however, become more pronounced as the quantity of the antibiotic goes up. The mechanical properties of the cement with antibiotics are similar with those of the regular cement, when low doses of antibiotics are used and become more evident as the doses go up. In conclusion, the antibiotic bone cement is a trustworthy tool in the surgeon’s arsenal against infection, with minimal detriments from the mechanical view.

The Analysis of Main Causes of Different Osteosynthesis Implants Failure in a Series of Clinical Cases

The study presented in this paper was conducted to assess the main causes of osteosynthesis implants failure, among which implant material defects and unstable osteosynthesis fixation occur. A total number of 42 patients with osteosynthesis implant failure were included in this study in the Orthopedics and Traumatology Clinic of Bucharest Emergency University Hospital. The osteosynthesis implants failure was determined using radiological examination, only the patients with the age between 18 and 60 were selected. From the total number of patient included in our study, 18 had osteosynthesis performed with open reduction and plates and screws fixation, 5 intramedullary implants with open reduction, 4 intramedullary implants with close reduction, 15 cases of fixation with locking screws. For evaluating the macroscopic and microstructural features of the failure, we use microscopically techniques like stereomicroscopy, optical microscopy and scanning electron microscopy (SEM) techniques in conjunction with radiological images. After our analysis, in 14 cases we found a correct fixation but the microscopic examination of the implant materials reveals cracks in their structure, 24 cases showed an imperfect reduction of the fracture with interfragmentary diastasis and malrotation, and 4 had inadequate size devices, where the examination of failed metallic implants revealed no structural defects in implant materials. The results of our study showed that both design errors and inappropriate surgical procedures were causes of osteosynthesis failure. Therefore, special attention should be paid to the surgical fixation procedure but also to the fixation implant materials used.

Bleeding Disorders – A Frequent Complication Related to the Use of Intrauterine Device with Low Dose Hormonal Mechanism of Action

Due to fact that an intrauterine device with low dose hormonal mechanism of action - the 13.5 mg levonorgestrel-releasing intrauterine system has been just launched in Romania, the undesirable reactions have not been studied and reported. This system has a hormonal mechanism of action, releasing progesterone, with a particular delivering rate of levonorgestrel. Bleeding irregularities are among the very common adverse reactions reported by phase II and III studies. We performed this study in order to determine a profile of bleeding disorders after 2 months of therapy with the 13.5 mg levonorgestrel-releasing intrauterine system.

Early Degradation of Resurfacing Prostheses

The resurfacing arthroplasty is a new method, superior techniques used in hip arthroplasty, through the immediate post-operative recovery and distance, followed by a complete reversal of limb function and a minimum rate of postoperative complications. Performance of this prosthesis is evident in well selected cases (young patients with physical activity) after a surgical indication correctly formulated. 39 patients with aseptic necrosis of the femoral head prosthesis underwent surgery with total hip resurfacing type in Clinical Orthopaedics-Traumatology, University Hospital Bucharest between 2005-2009. The diagnosis was established by X-ray and MRI examination. Sex ratio was: 22 men and 17 women. Age groups: 11 patients 20-30 years, 30-40 years 16 patients, 12 patients over 40 years... Approach was developed by postero-lateral joint capsule being maintained to preserve femoral vasculature. Recovery was fast in a short amount of time patients. All patients were reviewed clinically and radiographically at 4 weeks, 6 weeks, 3 months, 6 months, and 12 months, then annually. There were 5 cases of revision after resurfacing arthroplasty type of causes independent of design and composition of these prostheses. Revision surgeries of these prostheses have gone easier than in the case of conventional prostheses. Most times it is enough just replacing the stem, keeping torque meta-metal large head with all its benefits. The importance of this type of arthroplasty is that: are aimed at young people, preserves bone capital, maintain femoral vasculature, rapid, resumption of intense physical activity, complete recovery of movement in the hip joint, lack of formidable complications in hip arthroplasty dislocation represented.

A Failed Tibial Osteotomy - The Influence of Bone Mineral Substituent

In surgical experiences of the fractures of the proximal tibia, which are named tibial plateau fractures, with important damage of the articular surfaces of the tibia is very important to realise a correct reduction and an adequate osteosinthesys . But in real time this is a very difficult aim, because the correct reduction by various methods, induced an important bone deficiency. This is the principal aspect of the proximal tibial reconstruction, because this reconstruction s essential for the stability of the implant, for the correct reduction, for the correct allignemment of lower limb and for the reduction of the malunions results, for the abnormal consolidations and for devloppemment of the ostheoarthritis of the knee.We have two posibilities to reduce the bone gap - with bone grafts , by collaboration with the National Bone Bank , or by using a bone substituent - a new method of reconstruction.In our opinion, the bone graft is the perfect solution for recent fracture and the bone substituent is indicated for the severe difformities secondaries of articular surface.

Osteosynthesis Material Failure: Poor Fixation or Material Defect

Rising rate of high energy trauma, mainly due to increasing life expectancy of the population on a global scale in recent decades and more intense daily activity, involves the need to address the increase of more complex fractures, thus putting to the test the experience of trauma surgeon and the quality of various osteosynthesis materials. Metallic materials designed for orthopedic implants must present a group of properties that strength, biocompatibility and resistance to degradation (corrosion or wear) are of primary importance. To reach these objectives, the materials used in the manufacture of orthopedic implants must meet standard requirements. These requirements include primarily standard chemical composition, microstructure and macroscopic appearance. In this paper we present a study to determine the cause of degradation of osteosynthesis material. The most frequent causes of degradation include poor or unstable fixation of osteosynthesis or material defects. A valuation technique, including optical and scanning electron microscopy (SEM) was used to assess aspects of macroscopic and microstructural degradation and chemical composition of implants. These assessments showed that both design errors and inappropriate surgical procedures were due to failures.